U.S. USDA Form usda-fsa-440-32
This form is available electronically.
Form Approved - OMB No. 0560-0166
U. S. DEPARTMENT OF AGRICULTURE
Farm Service Agency
FSA-440-32
(06-03-02)
VERIFICATION OF DEBTS AND ASSETS
(See Page 2 for Privacy Act and Public Burden Statements)
PART A - INSTRUCTIONS: FSA OFFICIAL completes Items 2 through 3C, and have the APPLICANT complete Items 1 and 4A
through 8. This form is to be transmitted directly to the lender and is not to be transmitted through the applicant or any other
party.
2. FROM: (Address of FSA Office)
1. TO: (Name and Address of Financial Institution)
This certifies that the United States Department of Agriculture, acting through FSA, has complied with the applicable provisions of Title XI,
the Right to Financial Privacy Act of 1978, Public Law 95-630, in seeking financial information regarding the applicant(s) listed in Items
4A, 5A, and 6A.
3B. Title
3A. Signature of FSA Official
3C. Date (MM-DD-YYYY)
To Financial Institution: I have applied for assistance from the United States Department of Agriculture and have indicated that I owe a
debt to or have an asset invested with your firm. You are hereby authorized to provide the information requested below. Your response is
solely a matter of courtesy for which no responsibility is attached to your institution or its officers.
4A. Name and Address of Applicant
4B. Signature of Applicant
4C. Date (MM-DD-YYYY)
5A. Name and Address of Applicant
5B. Signature of Applicant
5C. Date (MM-DD-YYYY)
6A. Name and Address of Applicant
6B. Signature of Applicant
6C. Date (MM-DD-YYYY)
7A. Type of Loan or
Account No.
7B. Type of Loan or
Account No.
7C. Type of Loan or
Account No.
7D. Type of Loan or
Account No.
7. Type(s) of Loans (e.g., automobile equipment,
cattle and credit cards):
8. Account number(s) (e.g., checking, savings,
money market and mutual funds):
PART B - TO BE COMPLETED BY FINANCIAL INSTITUTION
A.
B.
C.
D.
9. Date of origination (MM-DD-YYYY)
10. Principal Balance
$
$
$
$
11. Accrued Interest
$
$
$
$
$
$
$
$
14. Previous 12-month high balance
$
$
$
$
15. Previous 12-month low balance
$
$
$
$
12. Daily Interest Accrual
13. Effective date of Items 10 and 11 (MM-DD-YYYY)
16. Current interest rate applicant is being charged
is earning
%
%
%
%
17. Installment or annuity amount
$
$
$
$
18. Amount past due
$
$
$
$
19. Description of collateral
20. Maturity date or final due date (MM-DD-YYYY)
The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national origin, gender, religion, age, disability, political beliefs, sexual
orientation, and marital or family status. (Not all prohibited bases apply to all programs.) Persons with disabilities who require alternative means for communication of program information (Braille, large print,
audiotape, etc.) should contact USDA's TARGET Center at (202) 720-2600 (voice and TDD). To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, Room 326-W, Whitten Building,
1400 Independence Avenue, SW, Washington, D. C. 20250-9410 or call (202) 720-5964 (voice or TDD). USDA is an equal opportunity provider and employer.
FSA-440-32 (06-03-02) Page 2
ALL INFORMATION PROVIDED WILL BE RELEASED TO THE APPLICANT AT THEIR REQUEST
21. Please rate the applicant's repayment record:
Prompt
Usually prompt
22. How many years has the applicant conducted
business with your firm?
Not prompt
YES
NO
23. Do your lien instruments, if applicable, contain a hereafter acquired clause?
24. Do your lien instruments, if applicable, contain a future advance clause?
25. Does your firm impose a penalty if the deposit or investment accounts described on this form are withdrawn prior to maturity?
26. Would you extend additional credit?
27. Would you extend additional credit with an FSA Guarantee?
28. Remarks
Federal statutes provide severe civil and criminal penalties for any person who knowingly makes false or fraudulent statements or
representations to a government agency or officer with the intention of influencing any action by such agency or officer.
29A. Signature of Financial Institution's Representative
NOTE:
29B. Title
29C. Date (MM-DD-YYYY)
30. Telephone Number
(Including Area
Code)
The following statements are made in accordance with the Privacy Act of 1974 (5 USC 552a), the Farm Service Agency (FSA) is authorized by the Consolidated Farm
and Rural Development Act, as amended (7 USC 1921 et seq.), or other Acts, and the regulations promulgated thereunder, to solicit the information requested on its
application forms. The information requested is necessary for FSA to determine eligibility for credit or other financial assistance, service your loan, and conduct
statistical analyses. Supplied information may be furnished to other Department of Agriculture agencies, the Internal Revenue Service, the Department of Justice or
other law enforcement agencies, the Department of Defense, the Department of Housing and Urban Development, the Department of Labor, the United States Postal
Service, or other Federal, State, or local agencies as required or permitted by law. In addition, information may be referred to interested parties under the Freedom of
Information Act (FOIA), to financial consultants, advisors, lending institutions, packagers, agents, and private or commercial credit sources, to collection or servicing
contractors, to credit reporting agencies, to private attorneys under contract with FSA or the Department of Justice, to business firms in the trade area that buy chattel
or crops or sell them for commission, to Members of Congress or Congressional staff members, or to courts or adjudicative bodies. Disclosure of the information
requested is voluntary. However, failure to disclose certain items of information requested, including your Social Security Number or Federal Tax Identification
Number, may result in a delay in the processing of an application or its rejection.
According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information
unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0560-0166. The time required to complete this
information collection is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and reviewing the collection of information. RETURN THIS COMPLETED FORM TO YOUR COUNTY FSA OFFICE.